Provider Demographics
NPI:1013586288
Name:MORENO, CHRISTINA MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 ADAIR ST APT B3
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2906
Mailing Address - Country:US
Mailing Address - Phone:219-308-2067
Mailing Address - Fax:
Practice Address - Street 1:4319 S LEE ST STE 300
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5752
Practice Address - Country:US
Practice Address - Phone:678-288-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist